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Tuesday, 3 September 2013

How to do a ward round

Till recently there were no accepted method, standard, process, protocol or
parameters on how a doctor should do a ward round for in-patients. We generally
turn up, see the patient, sort problems and when the patient gets better we
discharge the patient. In recent times there are emerging opinions which have
led to some recommendations on ward rounds.I describe my personal experience of one of the best ward rounds that I had
the privilege to be a part of during my training days. I describe the ward
rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General
Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the
ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants
emergency takes, outliers and consultation requests from other consultants- Write in the patient notes the results of investigations or have the
investigation results on hand ready to be written in the notes- Deal with any really dire emergencies where the physiology was really poorRegistrars should come in at 8.30 am and had till 9 am; their job was
defined:

- Help the house surgeon deal with dire emergencies if there were any- Talk to the nurses to identify any issues that arose overnight for the
in-patientsMr Desai would arrive at 9 am to the male ward. If there were any dire
emergencies the registrar (and not anyone else) would continue to deal with it.
Otherwise the whole team started the ward round. The whole team included the
ward sister and the nurse who looks after the patient apart from the house
surgeon, medical students if any, clinical attachment doctors if any and other
healthcare staff as relevant. What I call a ward round kit followed the team -
this included the notes trolley, all investigation request forms, a dictaphone,
gloves, gel, stationery (continuation sheets, consultation request forms), some
house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant.

Everything that the patient
needed as a result of the consultant visit was completed before moving on to
see another patient.

If a patient needed bloods to be repeated immediately it was done right
there in front of the consultant, bloods need to be repeated in the afternoon
or the next day the forms were done right there, any other test requests
(X-ray, CT, ECG, etc) were done then and there. Any communication with other
teams/speciality's consultants/registrars they were bleeped or rung, spoken to
or if they were not available a message was left with their secretaries.
Letters needing dictation though this was rare was done right there. A canula
that needed doing was done then and there. Every work that was generated as a
result of Mr Desai's ward round was done in the presence of Mr Desai or if
appropriate by Mr Desai himself as soon as it was generated before moving on to
the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds
took less than an hour (which was reasonable by surgical standards), Mr Desai's
ward round took all morning (his ward rounds were in the morning). It was
initially frustrating. But soon junior doctors realised that there were not
many 'to do lists' not many things to actually pending. We were not running
like headless chicken after the ward round. We ended up having more time for
the doctors mess, more time for learning, more time for everything else.Any really abnormal results were acted upon at the earliest as anyone would.
The next time the house surgeon had any serious work was at 3.30 pm to check on
any changes to patient's status which were not already informed and to check on
investigation results that were not direly abnormal and to act on it. Barring a
late finish in theatres Mr Desai would always visit the wards and speak to the
senior nurse at 5 pm every day and conducted the equivalent of a board round.
Any patients that needed to come to the attention of the on-call teams were noted
- Mr Desai would speak to the on-call consultant and Mr Desai's registrar would
speak to the on-call registrar. 5.30 pm we were gone.I do not know the precise results of Mr Desai's work. All I know was that
everyone including me was of the impression that his work was good. It was
organised, it was thorough and all elective work was directly consultant
delivered or delivered in the presence of a consultant. An aside which could be
a nugget as a mark of the quality of his work: all his patients who were having
elective major surgery were seen by the physiotherapist with a special emphasis
on chest physio - blowing balloons et al - it was no wonder we thought his
patients did well.I did not know about lean concepts in 1994. When I later became aware of
lean I realised that this is a single piece flow ward round if there was ever
such a thing described.I recommend it.

PS: I have heard a number of patients credit Mr Desai with commencing
gastrointestinal endoscopy, vascular surgery, endo-urology and triple
assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise
him.

2 comments:

I think this is fantastic. The only downside would be is if you had 40 patients, then it could take all day. Also sometimes more junior members of the staff need to see patients themselves in order to get into the groove of decision making. It is a great boon for the SHO's who get a lot of teaching and finish all their jobs and also amazing for the patients who get sorted straight away.

Like any method if it is practised it comes out smoothly. On some occasions when we have had a large number of patients (e.g. post on-call) of course it takes longer but everyone is more prepared so that the efficiency is not lost.

The consultant ward round was only twice a week, the rest of the days it was registrars making decisions (after seeking appropriate advice as needed).

You are right that from the patient's perspective this is perfect. That is what we should all be looking for.